Sleep apnea

Sleep apnea is a potentially serious condition that causes breathing to stop and start several times during sleep. People with the condition snore loudly and feel tired even after a full night of sleep.

The main types of sleep apnea are:

• Obstructive sleep apnea. Also known as OSA, this more common form of sleep apnea occurs when throat narrowing blocks the flow of air into the lungs.
• Central sleep apnea. Also known as CSA, this type of sleep apnea occurs when the brain doesn’t send proper signals to the muscles that manage breathing.
• Treatment-emergent central apnea syndrome, also known as complex sleep apnea. This form of sleep apnea happens when OSA — diagnosed with a sleep study — converts to CSA when receiving sleep apnea therapy.

Sleep apnea treatment can ease symptoms and might help prevent complications, such as heart problems.

The symptoms of obstructive sleep apnea and central sleep apnea overlap. Sometimes it’s hard to know which type you have. The most common symptoms include:

• Loud snoring.
• Episodes in which breathing stops during sleep, which would be reported by another person.
• Gasping for air during sleep.
• Awakening with a dry mouth.
• Morning headaches.
• Trouble staying asleep, known as insomnia.
• Excessive daytime sleepiness, known as hypersomnia.
• Trouble paying attention while awake.
• Irritability.

When to see a doctor

Loud snoring can indicate a potentially serious problem, but not everyone who has sleep apnea snores. Talk to your healthcare professional if you have symptoms of sleep apnea or any sleep problem that leaves you very tired, sleepy and irritable.

Obstructive sleep apnea and central sleep apnea have different causes.

Obstructive sleep apnea

This type of sleep apnea happens when the muscles in the back of the throat relax. These muscles support the back of the roof of the mouth, known as the soft palate. The muscles also support the tongue, tonsils, side walls of the throat, and the tissue hanging from the soft palate, called the uvula.

When the muscles relax, your airway narrows or closes as you breathe in. You can’t get enough air, which can lower the oxygen level in your blood. Your brain senses your inability to breathe and briefly wakes you so that you can reopen your airway. This awakening is usually so brief that you don’t remember it.

You might snort, choke or gasp. This pattern can repeat itself 5 to 30 times or more each hour, all night, affecting your ability to reach the deep, restful phases of sleep.

Central sleep apnea

This less common form of sleep apnea occurs when your brain fails to send signals to your breathing muscles. This means that you make no effort to breathe for a short period. You might awaken with shortness of breath or have a hard time getting to sleep or staying asleep.

Sleep apnea can affect anyone, even children, but certain factors raise your risk.

Obstructive sleep apnea

Factors that increase the risk of this form of sleep apnea, also known as OSA, include:

• Excess weight. Obesity greatly increases the risk of OSA. Fat deposits can block your upper airway and affect your breathing.
• A narrowed airway. You might have inherited a narrow throat. Tonsils or adenoids also can enlarge and block the airway, particularly in children. People with thicker necks also might have narrower airways.
• Sex assigned at birth. Men are 2 to 3 times more likely to have sleep apnea than are women. However, women’s risk is increased if they’re overweight or if they’ve gone through menopause.
• Being older. OSA is more common in older adults.
• Family history. Having family members with OSA might increase your risk.
• Use of alcohol or sedatives. These substances relax the muscles in your throat, which can worsen OSA.
• Smoking. Smokers are three times more likely to have OSA than are people who’ve never smoked. Smoking can increase the amount of inflammation and fluid retention in the upper airway.
• Nasal congestion. If you have trouble breathing through your nose, you’re more likely to start to get OSA. This can be due to your anatomy or allergies.
• Medical conditions. Congestive heart failure, high blood pressure and type 2 diabetes are some of the conditions that may increase the risk of OSA. Polycystic ovary syndrome, hormonal disorders and prior stroke also may raise the risk.

Central sleep apnea

Risk factors for this form of sleep apnea, also known as CSA, include:

• Being older. Middle-aged and older people have a higher risk of CSA.
• Sex assigned at birth. CSA is more common in men than it is in women.
• Heart disorders. Having congestive heart failure increases the risk.
• Using opioid medicines. Opioid medicines, especially long-acting ones such as methadone, increase the risk of CSA.
• Stroke. Having had a stroke increases your risk of CSA.

Sleep apnea is a serious medical condition. Complications of obstructive sleep apnea, also known as OSA, can include:

• Feeling very tired during the day. The repeated awakenings caused by sleep apnea make typical, restorative sleep impossible. In turn, OSA causes severe daytime drowsiness and irritability.

  You might not be able to concentrate or find yourself falling asleep at work, while watching TV or even when driving. People with OSA have an increased risk of motor vehicle and workplace accidents.

  You also might feel quick-tempered, moody or depressed. Children and teenagers with OSA might perform poorly in school or have behavior problems.

• High blood pressure or heart problems. Sudden drops in blood oxygen levels that occur during OSA increase blood pressure and strain the cardiovascular system. Having OSA increases your risk of high blood pressure, also known as hypertension.

  OSA also might increase your risk of recurrent heart attack, stroke and irregular heartbeats, such as atrial fibrillation. If you have heart disease, multiple episodes of low blood oxygen can lead to sudden death from an irregular heartbeat.

• Type 2 diabetes. Having OSA increases your risk of getting insulin resistance and type 2 diabetes.
• Metabolic syndrome. People with OSA can have this syndrome, which includes having hypertension, elevated cholesterol levels, high blood sugar and an increased waist circumference. This syndrome is linked to a higher risk of heart disease.
• Complications with medicines and surgery. OSA is also a concern with certain medicines and general anesthesia. People with OSA might be more likely to have complications after major surgery because they’re prone to breathing problems, especially when sedated and lying on their backs. Before surgery, it’s important to tell your healthcare professional about your OSA and how it’s treated.
• Liver problems. People with OSA are more likely to have irregular results on liver function tests. Their livers also are more likely to show signs of scarring, known as nonalcoholic fatty liver disease.
• Sleep-deprived partners. Loud snoring can keep anyone who sleeps nearby from getting good rest. Sometimes a partner has to go to another room, or even on another floor of the house, to sleep.

Complications of central sleep apnea, also known as CSA, can include:

• Feeling very tired. CSA causes repeated awakenings, making it very hard to get restful sleep. People with CSA often have daytime drowsiness and irritability. It interferes with concentration and can cause people to fall asleep at work, while watching television or even while driving.
• Cardiovascular problems. Sudden drops in blood oxygen levels that occur during CSA can affect heart health. If there’s underlying heart disease, repeated episodes of low blood oxygen increase the risk of irregular heart rhythms.

Sleep apnea may not be able to be prevented in everyone, but addressing risk factors can decrease the likelihood of breathing problems during sleep. To decrease OSA risk, healthcare professionals recommend losing excess weight, treating nasal congestion and not drinking more than a moderate amount of alcohol. To lower CSA risk, minimize your use of opioid medicines and see your healthcare professional if you have congestive heart failure.

To diagnose sleep apnea, your healthcare professional begins by asking about your symptoms and sleep history. Someone who shares your bed or household may be able to provide helpful information.

You’re likely to be referred to a sleep center. There, a sleep specialist can recommend further evaluation.

An evaluation often involves overnight monitoring at a sleep center, especially if your healthcare professional suspects that you have CSA. But home sleep testing also might be an option. Tests to detect sleep apnea include:

• Sleep study, also known as polysomnography. During this test, you’re hooked up to equipment that monitors your breathing patterns while you sleep. Your heart, lung and brain activity, arm and leg movements, and blood oxygen levels also are measured.
• Home sleep tests. Your healthcare professional might provide you with simplified home tests. These tests usually measure your heart rate, blood oxygen level, airflow and breathing patterns. Since home tests sometimes miss sleep apnea, your healthcare professional might still recommend polysomnography even if your first results are within the standard range.

If you have OSA, your healthcare professional might refer you to an ear, nose and throat doctor to rule out blockage in your nose or throat. You may need to see a heart specialist, known as a cardiologist, or a doctor who specializes in the nervous system, called a neurologist. They can look for causes of central sleep apnea.

For milder cases of OSA, your healthcare professional may recommend only lifestyle changes, such as losing weight or quitting smoking. You may need to change the position in which you sleep. If you have nasal allergies, your healthcare professional may recommend treatment for your allergies.

If these measures don’t improve your symptoms or if your apnea is serious, a number of other treatments are available. Certain devices can help open up a blocked airway. In other cases, surgery might be necessary.

Therapies for OSA

Many people successfully treat OSA with positive airway pressure, also known as PAP, therapies or oral devices. These therapies can prevent stops in breathing and make you more alert during the day.

• Continuous positive airway pressure, also called CPAP. You might benefit from using a machine that delivers air pressure through a mask while you sleep. With CPAP (SEE-pap), the air pressure is somewhat greater than that of the surrounding air. The greater pressure is just enough to keep your upper airway passages open, preventing apnea and snoring.

  Although CPAP is the most common and reliable method of treating sleep apnea, some people find it cumbersome and not comfortable. With practice, most people learn to adjust the tension of the straps on the mask for comfort and to find a secure fit.

  You might need to try more than one type of mask to find one with the right fit. Don’t stop using the CPAP machine. Check with your healthcare professional to see what changes can be made.

  Also contact your healthcare team if you’re still snoring or begin snoring again despite treatment. If your weight changes, the pressure settings of the CPAP machine might need to be adjusted.

• Other airway pressure devices. If using a CPAP machine continues to be a problem for you, you might be able to use a different type of airway pressure device that automatically adjusts the pressure while you’re sleeping, called auto-CPAP. Devices also can provide more pressure when you inhale and less when you exhale. This is known as bilevel positive airway pressure (BPAP).

• Oral appliances. Another option is wearing an oral appliance designed to keep your throat open. Typically, CPAP is more effective at opening the airway, but oral appliances might be easier to use. Some are designed to open your throat by bringing your jaw forward, which can sometimes relieve snoring and mild obstructive sleep apnea.

  Once you find the right fit, you’ll need to follow up with your dentist repeatedly during the first year and then regularly after that. This ensures a good fit.

• Myofunctional therapy. These are exercises that strengthen your upper airway muscles to reduce narrowing of the airway when you sleep. The exercises may be done along with other OSA therapies.

You’ll likely read, hear or see TV ads about different treatments for sleep apnea. Don’t try a new therapy before talking with your healthcare professional first.

Medicine for OSA

The U.S. Food and Drug Administration has approved the weight loss medicine tirzepatide (Zepbound) to treat obstructive sleep apnea in people with obesity. Clinical trials have found that people who took the medicine had fewer pauses in their breathing and better oxygen levels.

Tirzepatide is an injection taken every week. Side effects can include nausea, diarrhea, vomiting, constipation and stomach pain, among others. The medicine isn’t recommended for people who have had medullary thyroid carcinoma or family members who had the disease. It’s also not recommended in people with multiple endocrine neoplasia syndrome type 2.

Surgery for OSA

Surgery may be an option for OSA, but usually only if other treatments aren’t effective. Generally, at least a three-month trial of other treatment options is suggested before considering surgery. However, for a small number of people with certain jaw structures, it’s a good first option.

Surgical options might include:

• Tissue removal. During this procedure (uvulopalatopharyngoplasty), your healthcare professional removes tissue from the rear of your mouth and top of your throat. Your tonsils and adenoids usually are removed as well.

  This type of surgery might be successful in stopping throat structures from vibrating and causing snoring. It’s less effective than CPAP and isn’t considered a reliable treatment for obstructive sleep apnea.

  Removing tissues in the back of your throat with radiofrequency energy (radiofrequency ablation) might be an option if you can’t tolerate CPAP or oral appliances.

• Jaw repositioning. In this procedure, your jaw is moved forward from the remainder of your face bones. This enlarges the space behind the tongue and soft palate, making a blockage less likely. This procedure is known as maxillomandibular advancement.
• Nerve stimulation. A device implanted in your chest triggers the nerve involved in tongue movement, known as the hypoglossal nerve. The increased stimulation helps keep the tongue in a position that keeps the airway open. This treatment is used if nonsurgical treatments for OSA haven’t worked.
• Creating a new air passageway, known as tracheostomy. You may need this form of surgery if other treatments have failed and you have severe, life-threatening sleep apnea. In this procedure, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe. You keep the opening covered during the day. But at night you uncover it to allow air to pass in and out of your lungs, bypassing the blocked air passage in your throat.

Other types of surgery may help reduce snoring and contribute to the treatment of sleep apnea by clearing or enlarging air passages:

• Weight-loss surgery, also known as bariatric surgery.

Therapies for CSA

If you have CSA, your healthcare professional may recommend one of these therapies.

• Treatment for related medical problems. Possible causes of central sleep apnea include heart or neuromuscular disorders, and treating those conditions might help.
• PAP devices. Your healthcare professional may recommend CPAP or BPAP devices. A more recently approved airflow device is called adaptive servo-ventilation (ASV), also known as ASV. It learns your typical breathing pattern and stores the information in a built-in computer. After you fall asleep, the machine uses pressure to regulate your breathing pattern and prevent pauses in your breathing. ASV may be an option for some people with treatment-emergent central sleep apnea. However, ASV is not recommended for those with severe heart failure.
• Supplemental oxygen. Using supplemental oxygen while you sleep might help if you have CSA.
• Medicine changes. You may be prescribed medicine to help manage your breathing, such as acetazolamide. If medicines are worsening your CSA, such as opioids, your healthcare professional may change your medicines.
• Transvenous phrenic nerve stimulation. During this treatment, your healthcare professional implants a stimulator in your chest. The system affects the nerve involved in your breathing, known as your phrenic nerve. If the system detects that your breathing has stopped, it triggers the nerve to help you breathe.

Self-care might be a way for you to deal with obstructive sleep apnea and possibly central sleep apnea. Try these tips:

• Lose excess weight. Even a slight weight loss might help relieve constriction of your throat. In some cases, sleep apnea can resolve if you return to a healthy weight, but it can recur if you regain the weight.
• Exercise. Regular exercise can help ease the symptoms of obstructive sleep apnea even without weight loss. Try to get 30 minutes of moderate activity, such as a brisk walk, most days of the week.
• Avoid alcohol and certain medications, such as sleeping pills. These relax the muscles in the back of your throat, interfering with breathing.
• Sleep on your side or stomach rather than on your back. Sleeping on your back can cause your tongue and soft palate to rest against the back of your throat and block your airway. To keep from rolling onto your back while you sleep, try attaching a tennis ball to the back of your pajama top. There also are commercial devices that vibrate when you roll onto your back in sleep.
• Don’t smoke. If you’re a smoker, look for resources to help you quit.

If you or your partner suspects that you have sleep apnea, contact your healthcare professional. You might be referred right away to a sleep specialist.

Here’s some information to help you get ready for your appointment.

What you can do

When you make the appointment, ask if there’s anything you need to do in advance, such as modify your diet or keep a sleep diary.

Make a list of:

• Your symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment, and when they began.
• Key personal information, including family history of a sleep condition.
• All medicines, vitamins or supplements you take, including doses.
• Questions to ask your healthcare professional.

Take a family member or friend along, if possible, to help you remember the information you receive. Because your bed partner might be more aware of your symptoms than you are, it may help to have him or her along.

For sleep apnea, some questions to ask your healthcare professional include:

• What’s the most likely cause of my symptoms?
• What tests do I need? Do these tests require special preparation?
• Is my condition likely short term or long lasting?
• What treatments are available?
• Which treatment do you think would be best for me?
• I have other health conditions. How can I best manage these conditions together?
• Should I see a specialist?
• Are there brochures or other printed material that I can have? What websites do you recommend?

What to expect from your doctor

Your healthcare professional is likely to ask you questions, including:

• Have your symptoms been constant, or do they come and go?
• How severe are your symptoms?
• How does your partner describe your symptoms?
• Do you know if you stop breathing during sleep? If so, how many times a night?
• Is there anything that has helped your symptoms?
• Does anything make your symptoms worse, such as sleep position or alcohol consumption?

What you can do in the meantime

• Try to sleep on your side.
• Avoid alcohol for 4 to 6 hours before bed.
• Don’t take medicines that make you sleepy.
• If you’re drowsy, avoid driving.